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What surveyors want to see for review of med orders
Broader interpretation now is allowed
Most ED nurses breathed a sign of relief after The Joint Commission approved an interim action, effective Jan. 1, 2007, that changed the requirement for pharmacy review of ED medication orders (element of performance [EP] 1 for standard 4.10 of medication management). The new requirement allowed pharmacists to retrospectively review the orders, but just 14 weeks later, the action was suspended.
"I am extremely disappointed in the reversal of this action," says Alisa Murchek, RN, MS, associate director of nursing for the ED at University of Illinois at Chicago Medical Center. "This has been a huge challenge for our ED. To comply, we switched to an electronic fix, which interfaces pharmacy with the ED medication dispensing machine."
Now, when a medication is ordered electronically, the order is first verified by a pharmacist and then sent to the ED's automated medication dispensing machine. "A nurse can remove only verified medicines from the machine," she says. "We have the capability to override the verification process for medications such as those needed for rapid intubation."
The problem is that the new process causes delays, Murchek says. ED physicians can't always drop what they are doing to enter a drug order on the computer terminal, and nurses are accustomed to working fast and concurrently; a physician asks for a medication, and a nurse is on the way to get it while he places the order, she says. "With this new interface, there is a three-minute delay between the time the physician orders the drug and it is verified by a pharmacist and sent to the machine," she says. "It is amazing how an extra few minutes per patient can destroy an ED's overall throughput."
McKay-Dee Hospital Center in Ogden, UT, has been attempting to comply by staffing pharmacists in the ED. However, due to a shortage of pharmacists in Utah, they have coverage for only 12 hours a day, says Kayleen L. Paul, RN, CEN, director of emergency, critical care, and trauma services. "It's been difficult, costly, extraordinarily frustrating, and I honestly believe that the evidence does not support a safety need for this in the ED," she says. "Words cannot express the enormity of this challenge to our ED."
What went wrong?
According to Robert A. Wise, MD, vice president of The Joint Commission's Division of Standards and Survey Methods, the interim standard was put into effect because allowing retrospective review appeared to be a good solution. "We found that some people thought it was helpful, but we now had another group that told us we just made it worse," he says.
That group reported that they didn't have enough pharmacists to perform retrospective reviews of all the medication orders written in the ED. "We realized that there was no quick fix we could make that was going to clearly change for the better the processes going on in the ED," says Wise. "So instead of continuing to tinker here and there, we decided to instead go through the systematic process."
The Joint Commission is developing revisions to EP 1 for Standard MM 4.10 and will conduct a field review before finalizing those changes, he says. The revision process is expected to continue throughout 2007.
Since the interim action was suspended, the current standard now is reinstated as written in the 2007 accreditation manual. However, that standard has two exceptions for EP 1, and surveyors will be interpreting them more liberally. Kelly Podgorny, RN, MS, CPHQ, The Joint Commission's project director for the Division of Standards and Survey Methods, says, "The Joint Commission will now allow a more broad interpretation of these two exceptions in the ED as we go through the process of revising the standard."
The first exception allows for a prospective review to be bypassed if a licensed independent practitioner (LIP) controls the ordering, preparation, and administration of the medication. Now the medication can be processed by a nurse, and the LIP will not be required to remain at the bedside while the medication is administered.
"That is different from our previous position and allows a little bit more room for EDs to get that medication administered," says Podgorny. However, the LIP must remain available to provide immediate intervention in the event that the patient experiences an adverse medication event. For example, if an ED doctor is always available within the emergency department and is in immediate contact by radios carried by all staff, the requirement is met.
The second exception is for urgent situations when the resulting delay could harm the patient, including situations in which the patient experiences a change in clinical status. "What The Joint Commission will permit now, that we had not permitted previously, is to allow the LIP to define when a clinical situation is urgent. So whatever clinical situation the LIP determines is urgent and [thus] the prospective review is not conducted, The Joint Commission surveyors will accept this decision," says Podgorny.
For more information about pharmacy review of medication orders in the ED, contact:
The Emergency Nurses Association, American College of Emergency Physicians, and American Academy of Emergency Medicine jointly wrote a letter to The Joint Commission regarding standard MM 4.10. (To read the letter, go to www.ena.org.)
To access The Joint Commission's Urgent Bulletin — Update on Standard MM 4.10, go to: www.jointcommission.org